Delivery of Optimized Inpatient Anticoagulation Therapy

Consensus Statement From the Anticoagulation Forum

Edith A Nutescu PharmD FCCP; Ann K Wittkowsky PharmD CACP FASHP FCCP; Allison Burnett PharmD PhC; Geno J Merli MD FACP; Jack E Ansell; David A Garcia MD


The Annals of Pharmacotherapy. 2013;47(5):714-724. 

In This Article

1. Process

Every inpatient health care organization should use a system-based process for inpatient anticoagulation management to assure safe and effective use of these medications.

In 1999, the Institute of Medicine published its report To Err is Human: Building a Safer Health System,[13] which estimated that as many as 1 of every 25 hospitalized patients is injured due to medical error. Systems failures, rather than human error, are the cause of 75% of these errors.[14] In response, in 2002 the Institute for Safe Medication Practices introduced Pathways for Medication Safety,[15] a comprehensive set of tools intended to help hospitals adopt a "process-driven, system-based approach" to reduce medication errors and improve patient care. This launched an era in which hundreds of safe medication practices were implemented. However, the effectiveness of these practices was reduced by a lack of standardization at both the health system level and across organizations. The need for a well-defined, formally endorsed set of safe medication practices became evident. In 2003, the National Quality Forum, in conjunction with the Agency for Healthcare Research and Quality, introduced Safe Practices for Better Healthcare: A Consensus Report[16] in an effort to standardize medication safety processes. While not all-encompassing, this National Quality Forum report details 34 evidence-based practices that are generalizable to a wide variety of patient populations and care settings and, when properly implemented, are likely to have a significant impact on patient safety and outcomes. Some of these proven practices relate directly to anticoagulation management and have been adopted by the Joint Commission and other entities (Table 1).

For example, the use of standardized anticoagulation dosing protocols reduces errors and improves patient outcomes by providing evidence-based decision support, decreasing divergence in therapies, and facilitating timely monitoring of relevant laboratory parameters.[17–22] Clinicians should be encouraged to use these dosing protocols and order sets. They should be available on every floor and/or from the hospital's electronic medical record or intranet site. Implementation of technology, such as computerized physician order entry, bar code scanning, programmable infusion pumps, and dose range checking, is also associated with a decrease in medication errors.[23,24] Human or computer-based alert systems result in higher rates of appropriate VTE prophylaxis and reduction in thrombotic events.[25–28] While not all hospitals are able to implement technology-based systems, there are several systematic approaches to anticoagulation management that most hospitals should be able to use. One example is a multidisciplinary approach to anticoagulation management, such as having a pharmacist on rounds, which has been shown to reduce medication errors by up to 78%.[29] Pharmacy-driven inpatient anticoagulation management services have a positive impact on patient care and are another systems-based approach used to ensure safe and effective use of anticoagulants.[30–37] Regardless of the processes or systems used, the health care organization should create a culture of safety that encourages reporting and discussion of anticoagulation medication errors in a nonpunitive manner to promote identification of systems-based solutions.